| Eye exam established patient intermediate CPT 92012 • Ophthalmology | $86 | $86 | $86 |
| Eye exam established patient comprehensive CPT 92014 • Ophthalmology | $122 | $122 | $122 |
| Retinal imaging OCT posterior segment CPT 92134 • Ophthalmology | $14 | $27 | $39 |
| Ophthalmic biometry IOL power calculation CPT 92136 • Ophthalmology | $30 | $43 | $56 |
| Fundus photography CPT 92250 • Ophthalmology | $30 | $30 | $30 |
| Arthrocentesis aspiration intermediate joint CPT 20605 • Orthopedics | $30 | $34 | $38 |
| Arthrocentesis aspiration major joint CPT 20610 • Orthopedics | $68 | $68 | $68 |
| Cervical spine fusion anterior approach CPT 22551 • Orthopedics | $1,847 | $1,847 | $1,847 |
| Lumbar spine fusion posterior approach CPT 22612 • Orthopedics | $1,711 | $1,711 | $1,711 |
| Lumbar spine fusion combined approach CPT 22633 • Orthopedics | $1,801 | $1,801 | $1,801 |
| Reverse total shoulder replacement CPT 23473 • Orthopedics | $1,576 | $1,576 | $1,576 |
| Lateral epicondylitis open treatment CPT 24357 • Orthopedics | $412 | $427 | $442 |
| Tendon sheath incision trigger finger CPT 26055 • Orthopedics | $30 | $30 | $30 |
| Total hip replacement CPT 27130 • Orthopedics | $1,367 | $1,367 | $1,367 |
| Hip replacement conversion to total CPT 27132 • Orthopedics | $1,779 | $1,779 | $1,779 |
| Open treatment femoral fracture CPT 27236 • Orthopedics | $30 | $650 | $1,270 |
| Treatment intertrochanteric femoral fracture CPT 27244 • Orthopedics | $30 | $669 | $1,307 |
| Partial knee replacement medial or lateral CPT 27446 • Orthopedics | $30 | $630 | $1,229 |
| Total knee replacement CPT 27447 • Orthopedics | $30 | $698 | $1,366 |
| Open treatment tibial shaft fracture CPT 27756 • Orthopedics | $30 | $324 | $617 |
| Closed treatment distal fibula fracture CPT 27786 • Orthopedics | $30 | $30 | $30 |
| Bunionectomy with osteotomy CPT 28296 • Orthopedics | $30 | $477 | $923 |
| Arthroscopy shoulder decompression CPT 29826 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy shoulder rotator cuff repair CPT 29827 • Orthopedics | $30 | $584 | $1,137 |
| Arthroscopy knee with meniscectomy medial and lateral CPT 29880 • Orthopedics | $598 | $598 | $598 |
| Arthroscopy knee with meniscectomy CPT 29881 • Orthopedics | $576 | $576 | $576 |
| Arthroscopy knee with meniscus repair CPT 29882 • Orthopedics | $30 | $30 | $30 |
| Arthroscopy knee ACL repair CPT 29888 • Orthopedics | $21 | $26 | $30 |
| Discectomy lumbar single level CPT 63030 • Orthopedics | $30 | $506 | $981 |
| Laminectomy lumbar single level CPT 63047 • Orthopedics | $1,112 | $1,112 | $1,112 |
| Carpal tunnel release CPT 64721 • Orthopedics | $30 | $234 | $437 |
| Sacroiliac joint injection CPT 27096 • Pain Management | $30 | $30 | $30 |
| Epidural injection cervical or thoracic with imaging CPT 62321 • Pain Management | $258 | $258 | $258 |
| Epidural injection lumbar or sacral with imaging CPT 62323 • Pain Management | $253 | $254 | $255 |
| Spinal cord stimulator electrode implantation CPT 63650 • Pain Management | $30 | $1,159 | $2,288 |
| Peripheral nerve block injection CPT 64450 • Pain Management | $21 | $26 | $30 |
| Plantar common digital nerve injection CPT 64455 • Pain Management | $48 | $48 | $49 |
| Epidural injection lumbar or sacral transforaminal CPT 64483 • Pain Management | $241 | $241 | $241 |
| Epidural injection lumbar each additional level CPT 64484 • Pain Management | $30 | $30 | $30 |
| Facet joint injection lumbar first level CPT 64493 • Pain Management | $169 | $169 | $169 |
| Facet joint injection lumbar second level CPT 64494 • Pain Management | $88 | $88 | $89 |
| Chemodenervation of muscle migraine CPT 64615 • Pain Management | $150 | $152 | $154 |
| Facet joint nerve destruction lumbar first level CPT 64635 • Pain Management | $434 | $435 | $437 |
| Facet joint nerve destruction lumbar each additional CPT 64636 • Pain Management | $240 | $240 | $240 |
| Cytopathology concentration technique CPT 88108 • Pathology | $49 | $62 | $75 |
| Cytopathology cell enhancement technique CPT 88112 • Pathology | $78 | $78 | $78 |
| Cytopathology cervical/vaginal interpretation physician CPT 88141 • Pathology | $26 | $26 | $26 |
| Cytopathology cervical/vaginal manual screen CPT 88164 • Pathology | $13 | $15 | $18 |
| Cytopathology cervical/vaginal automated thin layer CPT 88175 • Pathology | $21 | $26 | $30 |
| Molecular cytogenetics DNA probe each CPT 88271 • Pathology | $24 | $24 | $24 |